Is preoperative ciliary body and iris anatomical configuration a predictor of malignant glaucoma development?

BACKGROUND: To investigate anatomical configuration of ciliary body and iris using ultrasound biomicroscopy as a predictor of malignant glaucoma development. DESIGN: Retrospective study in a tertiary care hospital. PARTICIPANTS: Cohort of 31 consecutive patients diagnosed with post-surgical malignant glaucoma. METHODS: Anterior chamber angle, iris and ciliary body configuration of involved eyes that had ultrasound biomicroscopy evaluation prior to the malignant glaucoma onset were evaluated. In cases with no presurgical ultrasound biomicroscopy exam of the involved eye, images from the fellow eye (imaged within 6 months) were analysed. MAIN OUTCOME MEASURES: Qualitative parameters. RESULTS: Thirty-one eyes (31 patients) had confirmed malignant glaucoma between 1996 and 2008. Most patients were women (65%) and had an anatomical narrow angle or angle-closure glaucoma (77%). Mean intraocular pressure at diagnosis was 30.4 ± 13.5 mmHg. The most common operation was trabeculectomy with mitomycin C (55%, 17/31 eyes), combined (3/17) or not (14/17) with cataract extraction and intraocular lens implantation. Among these 31 cases, we were able to evaluate the ultrasound biomicroscopy images of 13 patients (13 eyes) including involved eyes imaged prior to the malignant glaucoma onset or eligible fellow eyes. A narrow angle with or without iridotrabecular contact was found in all eyes. A large and/or anteriorly positioned ciliary body associated with an iris root angulating forward and centrally, revealing a plateau iris configuration, was noticed in 85% (11/13) of these eyes. CONCLUSION: Identification of plateau iris configuration by ultrasound biomicroscopy should be considered as a possible predictor of post-operative malignant glaucoma development.

Non-contact in vivo confocal scanning laser microscopy in exfoliation syndrome, exfoliation syndrome suspect and normal eyes.

PURPOSE: This study aimed to evaluate the efficacy of non-contact confocal laser microscopy in detecting structural alterations of the cornea, iris and lens in fellow eyes of patients with clinically unilateral exfoliation syndrome (XFS) and XFS suspects. METHODS: In a prospective observational case series, eyes of 12 patients with clinically unilateral XFS, six XFS suspects and six age-matched controls were divided into four groups. Group A included eyes with clinically visible exfoliation material (XFM) on the pupillary border or anterior lens capsule (n = 12); group B included fellow eyes of clinically unilateral XFS patients without visible XFM (n = 12); group C comprised eyes in XFS suspects with signs of pigment dispersion without visible XFM (n = 10), and group D consisted of control eyes with no evidence of XFM or pigment dispersion (n = 12). The cornea, iris and lens were imaged using a non-contact lens prototype for the Rostock Cornea Module (HRT II). Images were analysed by two observers masked to the clinical findings. RESULTS: Visible XFM (group A) on the lens capsule was characterized by hyperreflectivity in the granular and central disc areas and hyporeflective spaces in the intermediate zones. Similar hyperreflectivity was noted in four of 12 and one of 10 eyes in groups B and C, respectively, but in none in group D. Corneal endothelial hyperreflective deposits were found in eight of 12, four of 12 and one of 10 eyes in groups A, B and C, respectively, and no eyes in group D. CONCLUSIONS: This technology permits visualization of XFM and / or XFMrelated changes in the cornea and lens in the unaffected eyes of patients with clinically unilateral XFS. It may allow early detection of XFS and impact glaucoma screening and clinical surveillance decisions.

Bilateral Descemet membrane detachment after canaloplasty.

We report a case of bilateral Descemet membrane detachment (DMD) after canaloplasty in a 70-year-old Portuguese man with primary open-angle glaucoma. The patient developed bilateral DMD immediately following consecutive (1 week apart) canaloplasty surgery in both eyes. Slitlamp biomicroscopy, gonioscopy, and Fourier-domain optical coherence tomography (FD-OCT) findings are described. On postoperative day 1, in both cases, slitlamp biomicroscopy revealed an unscrolled inferonasal DMD and a clear cornea with deep and quiet anterior chambers. Gonioscopy showed an intact, lightly pigmented, and distended trabecular meshwork with no evidence of suture extrusion. High-resolution FD-OCT revealed a widely dilated canal of Schlemm, trabecular distention, and a retrocorneal hyperreflective membrane corresponding to a DMD. At 3 months, the DMD resolved spontaneously in both eyes. Although DMD is a known complication of canaloplasty, the occurrence of bilateral symmetrically located DMDs in our case suggests a possible anatomical predisposition in addition to factors induced by the surgical technique.

Serious complications of cosmetic NewColorIris implantation.

PURPOSE: This case report describes serious postoperative complications and markedly elevated intraocular pressure (IOP) associated with the NewColorIris cosmetic implant. METHODS: We report an interventional case series of two patients who suffered multiple complications after NewColorIris implantation carried out in Panama. Assessment included visual acuity, photography, endothelial cell count and anterior segment optical coherence tomography (OCT) when possible. RESULTS: Both patients presented with endothelial cell loss, uveitis, pigment dispersion and elevated IOP. Anterior segment OCT demonstrated irregularities in the position and configuration of the implants within the anterior chamber with resultant areas of implant-iris and implant-endothelial contact. One patient had acute postoperative hyphaema that resolved with anterior chamber tissue plasminogen activator injection. Both patients required explantation OU, one eye has required trabeculectomy, and one eye with bullous keratopathy is being evaluated for Descemet's stripping endothelial keratoplasty. CONCLUSIONS: Implantation of the NewColorIris cosmetic implant can lead to serious complications including hyphaema, uncontrolled IOP, severe endothelial cell loss, bullous keratopathy and anterior uveitis. Explantation may lead to improvement, but permanent damage to the trabecular meshwork and corneal endothelium persists.

Imaging of descemet membrane detachment after trabeculectomy using slit-lamp-adapted optical coherence tomography.

PURPOSE: To report the use of slit-lamp-adapted optical coherence tomography (SL-OCT) in imaging 2 patients with Descemet membrane detachment following anterior chamber reformation after trabeculectomy. METHODS: Two patients, with leaking and overfiltering blebs, respectively, developed Descemet detachments after reformation of flat anterior chambers with viscoelastics. Slit-lamp biomicroscopy and SL-OCT were used to diagnose and monitor posttreatment outcome. RESULTS: Biomicroscopic evaluation and SL-OCT imaging of the cornea revealed a Descemet detachment in both cases. One patient underwent intracameral air injection. Follow-up SL-OCT imaging revealed reattachment of Descemet membrane and reduced corneal thickness. CONCLUSIONS: SL-OCT can be used to document and follow postsurgical detachment of Descemet membrane.

In vivo imaging of the cornea in a patient with lecithin-cholesterol acyltransferase deficiency.

PURPOSE: To report high-resolution, in vivo imaging of the cornea in a patient with lecithin-cholesterol acyltransferase (LCAT) deficiency. METHODS: A 60-year-old Ecuadorian woman with bilateral corneal opacities and confirmed LCAT deficiency was imaged with Fourier domain optical coherence tomography (FD-OCT) and noncontact Rostock confocal laser scanning microscopy. RESULTS: The FD-OCT revealed a thinned epithelium, homogeneous hyperreflective stroma, and focal disruptions of Bowman's layer. Focal areas of hyperreflectivity with multiple dark striae and reduced and irregular keratocytes were seen throughout the stroma by noncontact Rostock module. The corneal endothelium was normal. CONCLUSION: New anterior segment in vivo imaging technology permits high-resolutional visualization and monitoring of corneal pathology.

Noncontact in vivo scanning laser microscopy of filtering blebs.

PURPOSE: To evaluate the ability of a noncontact, prototype scanning laser confocal microscope to image microstructural features of filtering blebs in vivo and to correlate these with the clinical features. METHODS: Thirty-one blebs of 24 patients underwent noncontact in vivo confocal microscopy using the Rostock Cornea Module of the Heidelberg Retina Tomograph II (50x noncontact Nikon lens, 1-2 mum resolution, field of view: 500x500 mum). Blebs were clinically classified as successful (low, diffuse, microcystic, and hypovascular) (n=22, mean intraocular pressure<20 mm Hg without hypotensive medications) or failed (flat, cicatrized, and nonfiltering) (n=9, mean intraocular pressure>20 mmHg with or without hypotensive medications). Multiple transverse images were taken over the scleral flap at 1 to 2 mm from the limbus. Images were evaluated by 2 observers masked to clinical appearance and function of the bleb. RESULTS: Transverse images of the successful blebs showed epithelial microcysts (50 to 100 microm) and small-sized to medium-sized (100 to 150 microm) subconjunctival cystic spaces with scattered loose collagen-like networks around the scleral flap. Failed blebs showed diffuse hyperreflective dense stroma, increased and tortuous vascularization, and no cystic spaces. The microscopic findings of all blebs were consistent with previous reports of contact in vivo confocal microscopy. CONCLUSIONS: Noncontact in vivo confocal microscopy of filtering blebs correlated with the clinical morphology. This noncontact approach provides information about bleb morphology without the risk of bleb microinjury, leak, or infection. Further study and optimization for imaging surface tissues are needed to improve our understanding of bleb maturation and wound healing.

Iris morphologic changes related to alpha(1)-adrenergic receptor antagonists implications for intraoperative floppy iris syndrome.

PURPOSE: To identify iris structural alterations associated with intraoperative floppy iris syndrome (IFIS) in patients using systemic alpha(1)-adrenergic receptor antagonists (alpha-1ARA). DESIGN: Cross-sectional study. PARTICIPANTS AND CONTROLS: Twenty-nine patients with current or past treatment with any systemic alpha-1ARA and 22 untreated controls. METHODS: Consecutive eligible patients underwent slit-lamp-adapted optical coherence tomography in a masked fashion under standardized lighting conditions. MAIN OUTCOME MEASURES: Iris thickness at the dilator muscle region (DMR; measured at half of the distance between the scleral spur and the pupillary margin) and at the sphincter muscle region (SMR; 0.75 mm from the pupillary margin), the ratio between the DMR/SMR (to compensate for possible intersubject variability), and pupillary diameter. RESULTS: Most treated patients were on tamsulosin (27/29). Mean age was similar in study and control groups (70.6+/-7.6 vs 67.1+/-9.1 years; P = 0.061). Photopic pupil diameter was reduced in the study group (2.06+/-0.5 vs 2.5+/-0.6 mm; P = 0.001). The SMR was similar between groups (P = 0.53). Significantly lower values were found in treated subjects for the DMR and the DMR/SMR ratio (P<0.001). These differences remained significant after adjusting for pupil diameter (P<0.001). Multiple regression analysis showed that a longer duration of alpha-1ARA treatment correlated to a reduced DMR/SMR ratio (P = 0.001; r = 0.47). Age and eye color were not significant in this model. CONCLUSIONS: Patients using systemic alpha-1ARA have significantly lower values of DMR thickness and DMR/SMR ratio and smaller pupil diameter when compared with age-matched controls. These differences seem to be related to the duration of drug exposure and provide evidence of structural alterations to the iris dilator muscle from this class of agents in IFIS. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Argon laser peripheral iridoplasty for topiramate-induced bilateral acute angle closure.

PURPOSE: To report a case of a topiramate-induced bilateral acute angle closure that was treated successfully by argon laser peripheral iridoplasty (ALPI). METHODS: A 59-year-old healthy woman taking oral topiramate developed bilateral acute angle closure. B-scan ultrasonography, ultrasound biomicroscopy, and slit-lamp adapted ocular coherence tomography were performed. RESULTS: The patient had shallow anterior chambers and total angle closure for 360 degrees OU. Ocular imaging showed circumferential ciliochoroidal effusions with anterior displacement of the iris-lens diaphragm. ALPI relieved the angle closure. CONCLUSIONS: ALPI should be considered as initial therapy for topiramate-induced acute angle closure.

Asymmetric progressive glaucomatous optic neuropathy in a patient with a rare developmental variant of the ophthalmic artery.

PURPOSE: To report a case of a developmental anatomic finding of the ophthalmic artery (OA) in a patient with ipsilateral progressive advanced glaucomatous optic neuropathy and visual field loss. METHODS: A 59-year-old Asian man with normal tension glaucoma had progressive asymmetric visual field loss OD. Magnetic resonance imaging and angiography of the orbit were performed because of continued progression despite medical and surgical intervention. RESULTS: Magnetic resonance angiography revealed an anomalous OA, lateral to the carotid artery and emanating from a branch of the middle meningeal artery. CONCLUSION: OA anomalies should be added to the differential diagnosis of risk factors for unilateral progressive glaucomatous optic neuropathy, and neuroradiologic imaging should be considered to detect such anatomic variants.

Anatomic relationships between disc hemorrhage and parapapillary atrophy.

PURPOSE: Parapapillary atrophy (PPA) and disc hemorrhage (DH) are associated with glaucoma. We sought to determine whether they are anatomically related. DESIGN: Retrospective study. METHODS: All digital optic nerve stereophotographs obtained over a one-year period were screened for the presence of DH. Only patients with DH were included. The location of the greatest beta zone PPA width as defined by the radial distance between the scleral rim and the outer border of the beta zone was compared in each patient. The clock hour location of the DH was determined. Baseline central corneal thickness, intraocular pressure, vertical cup-to-disc ratio, and visual field indices were obtained. RESULTS: Photographs from 1,559 glaucoma patients were evaluated and 46 eyes with unilateral DH were identified; 42 (91.3%) had beta zone PPA and 38 eyes had asymmetric PPA width. DH occurred more frequently in the eye with the greater PPA width (29/38 eyes [76.3%]; kappa = 0.611; P < .001). The DH fell on the point of greatest PPA width in 10 (23.9%) of 42 eyes (P < .05, Fisher exact test) and within two clock hours of the greatest PPA width in 31 (73.8%) of 42 eyes (P < .001, Chi-square test). Logistic regression analysis determined that greater PPA width (odds ratio, 17.16; 95% confidence interval, 5.34 to 55.12; P < .001) was the only ocular characteristic to predict the laterality of the DH. CONCLUSIONS: DHs tend to occur in the eye with the greatest PPA width and usually are found within the region of its greatest width.

Ultrasound biomicroscopy of zonular anatomy in clinically unilateral exfoliation syndrome.

PURPOSE: To evaluate the ability of ultrasound biomicroscopy (UBM) to detect abnormalities in the zonular apparatus in unaffected eyes of patients with clinically unilateral exfoliation syndrome (XFS) using a standardized grading system. METHODS: The affected and unaffected eyes of 17 patients with clinically unilateral XFS and 17 eyes of 17 control subjects underwent UBM. Radial sections detailing the lens and zonules at 12:00, 1:30, 3:00, 4:30, 6:00, 7:30, 9:00 and 10:30 clock hours were obtained. The images were graded by a masked, experienced UBM observer using a standardized scoring system based on the zonular appearance (0, none; 1 and 2, uneven or disrupted zonules with or without patchy deposits; 3, diffuse granulation, thick zonules or both; 4, total zonular disruption). Affected meridians were compared by the Friedman test, while distributions of unaffected and affected eyes were compared using the Student t-test. RESULTS: In the control group, 15/17 eyes showed normal zonules; the remaining two eyes showed grade 1 changes in some meridians. The mean grade score was 0.33 [standard deviation (SD) 0.84]. Eyes with XFS had a higher score than control eyes, with a mean score of 14.35 (SD 7.14, P < 0.001, Student t-test). In clinically unaffected fellow eyes, the mean score was 10.53 (SD 7.44), and was less than that of XFS eyes (P = 0.008, Student t-test). Twelve XFS eyes (71%) and six unaffected fellow eyes (35%) had grade 3 or 4 in at least one meridian (P = 0.07, Friedman test). CONCLUSION: Bilateral zonular involvement is present in subjects with clinically unilateral XFS. These zonular changes may be extensive in fellow eyes without clinically evident exfoliation material. UBM assessment of zonular status in fellow eyes prior to cataract extraction may aid in surgical planning.

Noncontact in vivo confocal laser scanning microscopy of exfoliation syndrome.

PURPOSE: To visualize structural alterations of the cornea, iris, and lens in patients with exfoliation syndrome (XFS) using a noncontact in vivo laser scanning confocal microscope and to correlate these with the clinical features. METHODS: The cornea, iris, and lens of 30 eyes with XFS were imaged using the Rostock Cornea Module of Heidelberg Retina Tomograph II (50x noncontact Nikon lens, an estimated 1 to 2 mum transverse resolution, 500x500-mum field of view). Serial transverse section images, as well as anterior segment photographs, were taken and analyzed. RESULTS: The corneal stroma and endothelium of 19 eyes (63%) showed different amounts and sizes of scattered small hyperreflective deposits. The irides revealed hyperreflective deposits on the anterior outer surfaces and/or pupillary margin corresponding to exfoliation material (XFM) and/or pigment granules. The anterior lens capsule showed varying degrees of peripupillary fibrillar hyperreflective deposits, hyperreflective areas with apparent epithelial cells centrally, and uniform epithelial cells in the clear intermediate zone. On the anterior capsule in 4 pseudophakic eyes, XFM appeared as hyperreflective round deposits. Hyperreflective floating deposits were seen in the aqueous humor in the pupillary region of the posterior chamber of 6 eyes (20%). CONCLUSIONS: Noncontact in vivo confocal microscopy permits visualization of XFM in the cornea, iris, and lens. This new technique may improve early detection of anterior segment abnormalities by providing information about subclinical cellular pathology, such as early pregranular XFS.

High-grade malignant B-cell lymphoma of the retina in a patient with concomitant gastric MALT lymphoma.

PURPOSE: To report the unexpected finding of a primary retinal B-cell lymphoma in a patient with previous breast carcinoma and subsequent lymphoma of the stomach. METHODS: Histopathologic and immunohistochemical findings in the enucleated eye are described in conjunction with clinical features and investigations. RESULTS: An 80-year-old woman with previous breast cancer presented with moderate loss of vision associated with vitreous opacities, circumpapillary retinal haemorrhages, and attenuated retinal vessels in her left eye. Treatment with systemic steroids and oral immunosuppressive drugs was initiated on suspicion of carcinoma-associated retinopathy. Two years later, the patient was diagnosed with MALT lymphoma of the stomach. Unfortunately, the ocular symptoms did not improve, and the patient developed neovascular glaucoma, for which the eye was eventually enucleated. Histopathology and immunohistochemistry as well as a molecular analysis revealed a primary B-cell lymphoma of the retina. CONCLUSION: Non-Hodgkin B-cell lymphoma of the retina should be considered as a differential diagnosis in cases of non-specific retinopathies even in the presence of other primary neoplastic co-morbidities.

Visual field changes in methotrexate therapy. Case report and review of the literature.

PURPOSE: To present a unilateral central visual field defect in a patient with psoriatic arthritis treated with Methotrexate and folic acid supplement, probably induced by toxic posterior optic neuropathy. The scotoma incompletely resolved after cessation of Methotrexate (MTX) therapy. METHODS: Serial fundoscopic, perimetric and electrophysiological examination as well as comprehensive neurological investigation including lumbar puncture, carotid sonography, electroneurography, and MRI of the brain. RESULTS: A female patient with psoriatic arthritis on long-standing Methotrexate (MTX 15 mg IM/once a week) therapy suffered first from an acute attack of central visual field defect in her right eye and later on from two subsequent deteriorations of her scotoma within one year. A demyelinating retrobulbar optic neuritis was excluded through repeated comprehensive neurological investigations and unresponsiveness to systemic corticosteroid therapy. A MTX-induced posterior optic neuropathy was suspected and the patient experienced improvement of her visual field defects only six weeks after discontinuing MTX therapy. Further improvement was observed through follow-up perimetric examinations half a year after cessation. CONCLUSIONS: Central scotoma with unremarkable optic disc can occur after long-standing treatment with MTX and despite folic acid supplementary therapy. This is most probably due to posterior optic neuropathy. Early cessation of the drug or change to another antimetabolite therapy can stop the deterioration of the visual field changes and even improve them. The exact pathomechanism is still unclear and the involvement of only one eye requires more investigation. MTX-induced posterior optic neuropathy should be included in the differential diagnosis of toxic optic neuropathy. This is getting more frequent than before because of the nowadays standard use of MTX in treatment of many autoimmune collagen diseases.

Loa loa macrofilariasis in the eyelid: case report of the first periocular subcutaneous manifestation in Germany.

PURPOSE: We report a case of periocular subcutaneous macrofilariasis as an initial sign of a systemic Loa loa infection. METHODS: Thorough history, eye examination and surgical intervention. Parasitological and serological analysis. RESULTS: A periocular adult Loa loa worm was extracted from the left upper eyelid in an African student living in Germany after presenting to our department with intermittent attacks of painful lid swelling. Four weeks later he presented with Calabar swellings in his arms without serological evidence of microfilaria and was treated with diethylcarbamazine. CONCLUSION: Due to increasing migration of populations to Europe rare manifestations of ocular loiasis are becoming more common. Intermittent painful eyelid swelling in patients who visited or have lived in Africa should always raise the suspicion of systemic loiasis.